1. Chapter 20 Personality Disorders

2. Public Health Concerns More than 1 in 10 adults in the community meet diagnostic criteria for at least one PD Relatively few evidence-based treatments are available for PDs PD diagnoses are associated with: – Hospitalizations – Criminal behavior – Dysfunction at work and in relationships – Suicidal behavior

3. Personality Disorder: DSM-5 Definition An enduring pattern of inner experience and behavior that: – Deviates markedly from the expectations of the individual’s culture – Is pervasive and inflexible – Has an onset in adolescence or early adulthood – Is stable over time – Leads to distress or impairment

4. Personality Disorder Clusters Cluster A – Schizotypal – Schizoid – Paranoid Cluster B – Antisocial – Borderline – Histrionic – Narcissistic Cluster C – Avoidant – Dependent – Obsessive-compulsive

5. Personality Traits Enduring features of personality that are: – Universal – Heritable – Linked to specific neurobiological structures and pathways – Well-characterized in terms of content and course – Valid for predicting a host of important life outcomes – Capable of reliable assessment, particularly via self-report questionnaires

6. Five-Factor Model (FFM) Represents the most viable model of normative personality traits Five normally distributed traits represent the broadest level of variation in personality: 1.Neuroticism 2.Extraversion 3.Openness to experience 4.Agreeableness 5.Conscientiousness

7. Cluster A Personality Disorders These disorders are phenomenologically and etiologically associated with psychotic disorders Distinguished from psychotic disorders by a lack of persistent psychotic symptoms (i.e., hallucinations and delusions)

8. Cluster A cont. Paranoid personality disorder – A pervasive pattern of distrust and beliefs that others’ motives are malevolent – Suspiciousness and consequent social dysfunction – Loose and hypervigilant thinking – Resentment

9. Cluster A cont. Schizoid personality disorder – A pervasive pattern of social detachment and restricted emotional expression – Disinterest in relationships and preference for solitude – Limited pleasure in sex or other activities commonly regarded as pleasurable – Emotional flatness

10. Cluster A cont. Schizotypal personality disorder – A pervasive pattern of interpersonal deficits, cognitive or perceptual distortions, and eccentric behavior – Loose or eccentric perceptions and cognitions – Flat affect – Mistrustfulness – Profound social dysfunction

11. Cluster B Personality Disorders Regarded as the “dramatic, erratic, and emotional” group Individuals with these disorders tend to experience emotional dysregulation and behave impulsively

12. Cluster B cont. Antisocial personality disorder – Pervasive pattern of disregard for the rights and wishes of others – Requires evidence of childhood conduct disorder – Socially non-normative behavior – Dishonesty – Impulsivity – Aggression – Lack of empathy – Irresponsibility

13. Cluster B cont. Borderline personality disorder – “Stable instability” in emotions, interpersonal behavior, and identity – Emotional dysregulation, including anger and emptiness – Emptiness is thought to be triggered by concerns about abandonment, which is followed by maladaptive coping, including impulsive and suicidal behavior

14. Cluster B cont. Histrionic personality disorder – Excessive emotionality and attempts to obtain attention from others – Often, attempts to gain attention are made via sexually provocative/flirtatious attire and behaviors – Desire to be the center of attention often comes at the cost of deep and meaningful interpersonal relationships – Tend to have relatively superficial interpersonal interactions and shallow emotions

15. Cluster B cont. Narcissistic personality disorder – Grandiose thoughts and behaviors – Need for excessive admiration from others – Lack of empathy – Commonly believed that arrogant and haughty behavior is caused by extreme feelings of vulnerability and inadequacy

16. Cluster C Personality Disorders Grouped together based on their common thread of anxiety and fearfulness

17. Cluster C cont. Avoidant personality disorder – Social inhibition rooted in feelings of inadequacy and fears of negative evaluations from others – Avoidance of social and occupational opportunities – Fears of shame and ridicule – Negative self-concept

18. Cluster C cont. Dependent personality disorder – Excessive need to be cared for by others that leads to submissive, clingy behavior – Difficulties with making autonomous decisions or expressing disagreement with others – Nonassertiveness – Preoccupation with abandonment – Maladaptive or self-defeating efforts to seek and maintain relationships

19. Cluster C cont. Obsessive-compulsive personality disorder – Preoccupation with order, perfection, and control in which flexibility, efficiency, and even task completion are often sacrificed – Preoccupation with rules, work, interpersonal inflexibility, frugality, and stubbornness

20. Epidemiology Prevalence rates have been determined with groups that have been diagnosed with categorical taxonomy and are, therefore, suspect Overall prevalence rates estimate 10% of individuals suffer from a PD during their lifetime Individual prevalence rates vary from 0.5% to 5% – Paranoid, avoidant, and obsessive-compulsive PDs relatively common – Dependent and narcissistic relatively uncommon – PDs are more common in psychiatric settings (primarily borderline and dependent)

21. Etiology Genetics – Heritability of personality pathology and disorders remains very ambiguous – 58% of the variance in twin study was accounted for by genetics – Paranoid (.30), schizoid (.31), schizotypal (.62), borderline (.69), histrionic (.67), narcissistic (.77), avoidant (.31), dependent (.55), and obsessive- compulsive (.78) – Rates of schizotypal and borderline PDs are higher among family members of individuals with those disorders – Rates of Cluster C PDs are increased among individuals who have relatives with anxiety disorders

22. Etiology cont. Neurobiology – Endophenotypes Cognitive dysregulation Emotional regulation Impulsivity Learning and cognition – Automatic thoughts, cognitive distortions, and interpersonal strategies

23. Course and Prognosis Although PD diagnosis is made after age 18, pathological features should be present during adolescence and early adulthood Most personality disorders tend to decline in middle age Stability of personality disorders seems to be lower than was once thought Treatments have shown benefit for at least some personality disorder symptoms

24. Treatment Limited evidence that psychopharmacology is effective for treating PDs – Likely to benefit certain symptom constellations (e.g., the emotional lability of borderline PD or the cognitive slippage of schizotypal PD) Issues with effectiveness of psychosocial treatments – Relatively high rates of early dropout, particularly in borderline PD – Substantial diagnostic complexity – Tendency for PD treatment to be unpleasant for clinicians, who may consequently exhibit iatrogenic behavior

25. Treatment cont. Borderline PD – Dialectical behavior therapy – Transference-focused therapy – Schema-focused therapy – Psychiatric management – Mentalization-based therapy